physical rehabilitation for the management of canine hip

Physical Rehabil itation forthe Management of CanineHip Dysplasia

David L. Dycus, DVM, MS, CCRPa,*,David Levine, PT, PhD, DPT, CCRP, Cert DNb,Denis J. Marcellin-Little, DEDVc

INTRODUCTION

Canine hip dysplasia (CHD) causes diffuse joint inflammation and subsequent coxo-femoral osteoarthritis (OA).1,2 Hip dysplasia was identified in more than 40% ofgolden retrievers and Rottweilers in 1 report.3 Hip dysplasia was originally describedmore than 80 years ago, but its exact etiology remains unknown; however, it is

Disclosure: The authors have nothing to disclose.a Department of Orthopedic Surgery, Veterinary Orthopedic and Sports Medicine Group(VOSM), 10975 Guilford Road, Annapolis Junction, MD 20701, USA; b Department of PhysicalTherapy, University of Tennessee at Chattanooga, 615 McCallie Avenue, Chattanooga, TN37403, USA; c Department of Clinical Sciences, College of Veterinary Medicine, North CarolinaState University, NCSU CVM VHC #2563, 1052 William Moore Drive, Raleigh, NC 27607, USA* Corresponding author.E-mail address: [email protected]

KEYWORDS

! Hip dysplasia ! Osteoarthritis ! Hip laxity ! Therapeutic modalities! Triple pelvic osteotomy ! Juvenile pubic symphysiodesis! Femoral head and neck ostectomy ! Total hip replacement

KEY POINTS

! The goals of rehabilitation at various stages of canine hip dysplasia vary; initially, clinicalsigns and discomfort are thought to be due to underlying laxity.

! Laxity results in lateralization of the femoral head during the swing phase of the gait with a“catastrophic reduction” of the femoral head into the acetabulum during foot strike.

! Conservative management is centered around maintaining pain control and comfort whileimproving hip range of motion in extension and muscle mass.

! Surgical therapy focuses on improving femoral head coverage and reducing the develop-ment of osteoarthritis or removing the source of discomfort.

! Each aspect of rehabilitation such as manual, therapeutic, and physical modalities followsa multimodal patient-centered approach.

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considered multifactorial with both genetic and environmental cues playing a role inits phenotypic expression.3 The central theme surrounding CHD is hip laxity, which isthought to play a major role in the development of OA. Hip laxity permits subluxationduring growth, which results in abnormal development of the acetabulum andfemoral head. The repetitive subluxation and reduction lead to excessive cartilagewear and damage to the dorsal acetabular rim, leading to OA. OA progresses overtime.4 Management of CHD is centered around both conservative and surgical ther-apies, as well as the age of the onset of clinical signs.4–6 Physical rehabilitation willplay a role in the management of CHD, with either conservative or surgical therapiesby providing pain relief through strengthening, maintaining range of motion (ROM),promoting optimal weight, and environmental modifications if needed. The purposeof this article is to present the rehabilitation steps that can be implemented tomanage CHD at its various stages.

PHYSICAL REHABILITATION IN THE CONSERVATIVE MANAGEMENT OF HIP DYSPLASIA

Although CHD has been analyzed in several hundred scientific publications, fewpublications discuss the conservative management of OA in dogs, and fewerhave assessed the long-term clinical signs and progression of OA.7 The approachshould be multimodal, with goals to improve function, reduce clinical signs ofpain, improve hip ROM and strength, and thus potentially slow down or minimizethe progression of OA. Given that the goal of conservative management of CHDis aimed at trying to improve the coxofemoral joint environment, many of the recom-mendations for management are similar to the management of OA. Loss of motion inOA patients results from the development of osteophytes and enthesophytes, thick-ening of the synovium, and from potential changes in muscle fiber elasticity. Motionshould be assessed at regular intervals using goniometry as an objective assess-ment.8 Loss of limb strength, core strength, and cardiovascular fitness resultsfrom a decrease in spontaneous activity, a decrease in owner-supervised exercise,and a reflex inhibition of muscle contractions (secondary to joint pain).9 Although OAin dogs is most often diagnosed on radiographs, osteophyte size and severity ofclinical signs correlate poorly. As a consequence, the management of OA shouldnot be based on radiographic appearance, but rather on the specific physical limi-tations of the patient. The goals of conservative management of CHD and the asso-ciated OA are accomplished by weight reduction, minimizing joint pain,pharmaceuticals, disease-modifying osteoarthritic agents, manual therapy, thera-peutic exercises, and physical modalities. Weight reduction, minimizing joint pain,pharmaceutical, and disease-modifying osteoarthritic agents are covered elsewherein this issue.

Manual Therapy to Minimize Joint Pain

Nonpharmacologic, antiinflammatory options for peripheral pain management includecold therapy (icing) and massage. Icing provides direct pain relief by decreasing nerveconduction velocity. It also provides secondary pain relief by decreasing edema (itselfa source of pain) and decreasing the overactivity of catabolic enzymes in osteoarthriticcartilage.10,11 Icing should be considered in osteoarthritic patients with flare-ups, aftera period of exercise, and before bedtime. Ice cubes or frozen vegetables are not rec-ommended because they have large air pockets that decrease cold conduction. Icebags filled with ice chips or crushed ice or cold packs provide more effective cold de-livery. Most cold packs reach therapeutic temperatures after 2 hours in a freezer. Forlonghaired patients, place and hold an ice bag or cold pack directly on the pet’s

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arthritic joint or joints and secure it with a self-adhesive band. A towel may be usedbetween the cold pack or bag and the skin in patients with short or no hair. Somecold packs have built-in self-adhesive bands. A neoprene sleeve may also be usedto secure a cold pack or bag. Icing should last for 10 to 15 minutes to achieve effectivecooling (Fig. 1).10 Most dogs tolerate the treatment, but should not be left unattended.The person applying the ice should make sure the patient is not uncomfortable andthat the skin surface feels cold to the touch after icing.Additional nonpharmacologic options for central pain management include low-

level heating, massage, and possibly acupuncture, acupressure, and electroacupunc-ture. The short-term and long-term effects of massage in companion animals are notknown. Massage may decrease myofascial pain and muscle tension.12 Thesemethods primarily stimulate Ab sensory fibers with rapid conduction velocities (30–70 m/s), sparing pain fibers with slower conduction velocities: Ad (12–30 m/s) and Cfibers (0.5–3 m/s). Heat is widely considered to positively impact painful OA patients(Fig. 2).11 The use of heat is 2-fold. Low-level heat (elevation of tissue temperatureby 1–2"C) relieves pain through the stimulation of nonnociceptive Ab sensory fibers,as well as the vasodilation and normalization of blood flow. This low-level tissue relax-ation may be achieved by keeping osteoarthritic patients in relatively dry and warmtemperatures throughout the day (eg, sleeping in heated indoor environments orproviding heated beds). More intense heat (elevation of tissue temperature by 3–4"C) is used to increase the effectiveness of stretching while minimizing tissue dam-age. Intense heating is most often applied by a health care professional using a hotpack that is heated by a hydrocollator or microwave oven. Four layers of dry towelsare generally placed between a hot pack and the skin, and heat is generally appliedfor 10 to 20 minutes.13 Caution must be used when placing a hot pack on a dogbecause burns can occur. Initially, the packs may not seem to be excessively hot tothe touch, but they can induce thermal damage after several minutes of contact.Furthermore, it is not recommended to use heating pads in place of a hot pack. Check-ing for excessive redness, skin swelling, or blistering every few minutes during intenseheat therapy is important.

Therapeutic Exercises to Minimize Joint Pain, Maintain or Increase Joint Motion

To help with minimizing joint pain and increasing joint motion in the hip, active andpassive ROM along with stretching exercises are important (Fig. 3). Little is knownabout the impact of OA on joint motion: dysplastic hips seemingly lose extensionbut not flexion, dysplastic elbows primarily lose flexion, and arthritic stifles lose

Fig. 1. Limb cryotherapy can be done using (A) a cold pack wrapped around the hind limb,(B) cryotherapy to the stifle, or (C) cryotherapy to the carpus. (From Millis D, Levine D.Canine rehabilitation and physical therapy. 2nd edition. Philadelphia: Saunders; 2016. p.318; with permission.)

Rehabilitation for Canine Hip Dysplasia 825

extension. In 1 study, Labrador retrievers with hip dysplasia had on average adecrease of 1" hip extension for each year of life.14 Minor (<10") loss of joint motionis unlikely to impact limb function, but severe loss of joint motion will likely lead tothe dog’s inability to gallop, trot, jump up, or climb steps or stairs. It seems to be bene-ficial, therefore, to assess joint motion in dogs with chronic CHD through the use ofgoniometric measurements.9 Because it is much easier to maintain joint motionthan to regain it when lost, it seems reasonable to recommend intermittent physicalactivity that leads to enhanced joint extension (compared with walking on a flat sur-face) without creating significant clinical signs. Passive ROM, active ROM, andstretching can be incorporated into the early phases of rehabilitation for CHD andcontinued as part of the daily exercise plan. These activities can help to increase flex-ibility, prevent adhesions, remodel periarticular fibrosis, and improve extensibility.15

Passive ROM is completed without muscle contraction by moving the joint throughits full ROM. Any additional force applied at the end of the ROM and held for at leasta few seconds is defined as stretching. If regaining joint motion is deemed important, astretching program should be implemented. Stretching is more effective when tissuesare heated immediately before and during the stretching session. Passive and active

Fig. 2. A hot pack is applied over a dog’s hip region. (From Millis D, Levine D. Canine reha-bilitation and physical therapy. 2nd edition. Philadelphia: Saunders; 2016: p. 324; withpermission.)

Fig. 3. Passive range of motion to the hip is completed by supporting the femur in 1 handand the pelvis in the other. (A) Hip flexion. (B) Hip extension. (From Millis D, Levine D.Canine rehabilitation and physical therapy. 2nd edition. Philadelphia: Saunders; 2016. p.437; with permission.)

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ROM in patients with CHD can be beneficial in the early phases of rehabilitation tofacilitate appropriate periarticular fibrosis that develops from laxity in younger patientsor help to realign fibrous tissue along lines of stress in older patients with clinical OA.Additionally, ROM and stretching can be incorporated into part of the daily exerciseprogram to maintain mobility between soft tissue layers, enhance blood and lymphaticflow, and improve synovial fluid production.16 Ideally, ROM and stretching are totissues that are warmed up; therefore, as part of a daily exercise program ROMand stretching can be completed after therapeutic exercises as part of the cooldown process. In the early phases of rehabilitation therapy passive ROM and stretch-ing can be performed 2 to 4 times daily for 10 to 20 repetitions. When used as part ofthe cool down process, ROM and stretching are performed at the end of theexercise program for 15 to 30 repetitions for ROM. For stretching, we empiricallyrecommend performing ten to fifteen 20- to 40-second-long sustained stretches dur-ing each session. Sessions may be performed 2 to 3 times per day. With chronic lossof motion, a weekly gain of 3" to 5" of joint motion is anticipated. A thorough explana-tion of how to perform ROM and stretching exercises is beyond the scope of thisarticle, and can be found elsewhere.17,18 Joint mobilization may also be incorporatedinto a rehabilitation program to help increase ROM. Joint mobilization differs fromstretching in that when a stretch is applied, a low load is placed on the tissues for aspecified amount of time (usually 10–30 seconds) to facilitate elongation. In joint mobi-lization, the force is applied in an oscillatory manner rather than a sustained manner(Fig. 4).Along with considerations for maintaining and improving joint ROM, proprioception

can be affected in patients with OA from chronic CHD. Although little is known aboutthe negative impact of naturally occurring OA on proprioception in dogs, there is clearevidence that OA progresses rapidly in patients with joint injuries that have sensorydeficits. In older humans with decreased proprioception, balance exercises readilyimprove proprioception.19 In dogs with OA, it is logical to dedicate a small portionof the exercise program to focus on proprioception and balance. In the early phases,this may include weight-shifting exercises (Fig. 5) requiring rapid and unpredictableside-to-side weight shifts and, to a lesser extent, front-to-back and back-to-front

Fig. 4. Joint mobilization to the hip uses a caudal glide to increase hip flexion. The blackarrow indicates the direction of the mobilization. (From Millis D, Levine D. Canine rehabil-itation and physical therapy. 2nd edition. Philadelphia: Saunders; 2016. p. 437; withpermission.)


weight shifts. This is completed by supporting the animal on either side and gentlypushing on 1 side, followed by pushing back the other way. The weight-shifting exer-cises should be done in a slow, rhythmic fashion for 15 to 25 repetitions, 2 to 4 timesdaily. As balance and proprioception improve, perturbation exercises can be added tothe weight shifting with the goal being to disturb the patient’s balance just enough for itto recover, but not so much force that the animal falls. Perturbation exercises are per-formed by gently pushing the animal at the hips without supporting the other side.More complex weight-shifting exercises can be incorporated while the patient iswalking to improve dynamic stability. Gently bumping or pushing the animal to 1side as it is walking to challenge the dog to maintain its balance is 1 way to furtherimprove proprioceptive function.Additional proprioception and balancing exercises include balance boards, wobble

boards, and exercise balls and rolls. A balance board uses a board placed over afulcrum to rock the dog side to side or forward to backward (Fig. 6). A more chal-lenging aspect to balance and proprioception improvement is using a wobble board(Fig. 7). Exercise balls and rolls that have been developed for human exercises canbe used to improve balance, coordination, and strength. For example, the front limbscan be placed on the ball requiring the dog to maintain static balance of the pelvic

Fig. 5. Weight shifting being applied to the pelvic limbs. This is accomplished by the thera-pist behind the patient and the hands on either side of the pelvis for support. Pressure isgently applied to 1 side then applied to the other side in a slow, rhythmic fashion. (FromMillis D, Levine D. Canine rehabilitation and physical therapy. 2nd edition. Philadelphia: Sa-unders; 2016. p. 487; with permission.)

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limbs (Fig. 8). For dynamic challenges, the ball can be rolled forward, backward, andfrom side to side. This challenges the limbs to maintain balance asmovement is occur-ring. The most challenging use of the exercise balls and rolls is having the patientstand on the therapy ball or roll. This exercise will challenge and engage multiplecore stabilizing muscles; therefore, the sessions should be short to avoid fatigueinjury.Other exercises that promote balance and proprioception include standing or

walking on foam rubber (Fig. 9), mattresses, air mattresses, or trampolines. Further-more, patients can be walked on various surfaces such as grass, concrete, sand,mulched paths. Altering the texture and evenness of the surface challenges patients’proprioceptive abilities. To facilitate improving balance and proprioception for daily

Fig. 6. A balance board is used to provide balance and proprioceptive training (A) from thefront limbs to the hind limbs and (B) from side to side. (FromMillis D, Levine D. Canine reha-bilitation and physical therapy. 2nd edition. Philadelphia: Saunders; 2016. p. 491; withpermission.)

Fig. 7. Awobble board creates a challenging hind limb exercise for balance and propriocep-tive training. (From Millis D, Levine D. Canine rehabilitation and physical therapy. 2nd edi-tion. Philadelphia: Saunders; 2016. p. 491; with permission.)


Fig. 8. An exercise ball can improve hind limb balance, coordination, and strength. (FromMillis D, Levine D. Canine rehabilitation and physical therapy. 2nd edition. Philadelphia: Sa-unders; 2016. p. 491; with permission.)

Fig. 9. When walking on foam rubber, the uneven terrain challenges the patient’s func-tional balance and proprioception. (From Millis D, Levine D. Canine rehabilitation and phys-ical therapy. 2nd edition. Philadelphia: Saunders; 2016. p. 492; with permission.)

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activities, animals should be encouraged to walk over or around obstacles such as lowrails, pole weaving, walking on a teeter-totter, and negotiating stairs.Additional therapeutic exercises that can be incorporated into formal rehabilitation

therapy and a home exercise program should be geared toward continued improve-ment in ROM, specifically in extension of the hip as well as improving weightbearing in a comfortable manner along with building muscle mass and improvingmuscle fatigue. In structuring a rehabilitation plan for the conservative managementof CHD, some basic biomechanics of exercise modification should be understood.Furthermore, the reader is encouraged to learn the biomechanics of physical rehabil-itation and kinematics of exercise that can be found elsewhere.19 The patient shouldwarm up for 5 to 10 minutes before therapeutic exercises.The simplest of the therapeutic exercises consists of slow, controlled leash walking.

Walking can be instituted in the early phases of rehabilitation and can be continuedthroughout. With regard to the hind limbs, walking will generate approximately 35"

of motion in the hip and 40" and 35" of motion in the stifle and hock, respectively.20,21

Treadmill walking (up to 10" of incline) has been shown to result in the same joint mo-tions as land walking; however, up to 3" of hip extension can be obtained while walkingon a inclined (10") treadmill when compared with walking on land.19 Although trottingis ideal to increase the speed of muscle contractions and the forces on the limb, itdoes little to improve ROM in the terms of hip motion compared with walking.22

Walking up and down stairs or a ramp can facilitate additional flexion and extensionto particular joints; however, some consideration has to be placed on the particular ex-ercise for CHD management. For example, incline ramp walking can increase hipflexion by 11%, but does not contribute to improvement in hip extension, which is tar-geted more commonly in patients with CHD.23 Walking up stairs is a very good exer-cise for improving hind limb ROM, such that hip extension can be increased by up to10" and is greater when compared with walking on level ground (Fig. 10).24 Stairdescent results in greater total ROM in the hip (27") compared with ramp descent(23").25

Having the knowledge of the kinematics of various walking exercises, one is able tocreate a plan to improve hip ROM as well as improve muscle mass and comfort. Forexample, in the beginning stages one may use slow controlled leash walking on levelground beginning at 15- to 20-minute intervals 2 to 3 times daily. Once the animal hasdeveloped the ability to perform this comfortably, 5 minutes can be added weekly tobuild up to 30 to 45 minutes. Inclined walking along with stair ascent and descent canbe added after several weeks of flat land walking to further improve hip ROM and

Fig. 10. Walking up stairs to improve hip extension more so than walking on level ground.(A) Stairs with a gradual rise. (B) Steeper stairs can be used as the patient progresses. (FromMillis D, Levine D. Canine rehabilitation and physical therapy. 2nd edition. Philadelphia: Sa-unders; 2016. p. 509; with permission.)


muscle mass. It is also beneficial to add in walking down a declined slope and walkingover uneven terrain. Walking on uneven terrain (trail walking, walking through highgrass, walking or on sand) forces the patient to increase flexion and extension ofvarious joints to navigate the terrain. All walking exercises should be completed in astepwise manner, only adding more challenging aspects after the patient has suc-cessfully completed easier tasks.Additional therapeutic exercises such as dancing, Cavaletti rail walking, and sit-to-

stand exercises can all help with improving ROM in the hip as part of conservativemanagement for CHD. These exercises can be completed as part of a home exerciseprogram or during formal rehabilitation therapy. Dancing exercises (Fig. 11) aredesigned to increase weight bearing on the rear limbs. This is accomplished by raisingthe forelimbs off the ground and walking the patient either forward or backward. Inter-estingly, different kinematics are accomplished by walking the dog forward versusbackward. Dancing forward will result in less hip flexion and total hip ROM (22")compared with walking on level ground (total hip ROM, 33"). Alternatively, dancingbackward increases hip extension more than walking on level ground. This differenceplays an important role in deciding on what direction dancing exercises should be per-formed. For example, during the early phases of rehabilitation when hip extension ispainful, it may be more comfortable to improve gluteal muscle strengthening bywalking the patient forward rather than backward. However, in the later phaseswhen hip extension is improved, walking the patient backward will be more chal-lenging and help to further improve hip extension.26 Total hip ROM is increased by us-ing Cavaletti rail walking (Fig. 12). That increase is proportional to the height of therails. For example, total hip ROM is improved by 2" (38" total ROM) compared withwalking (36" total ROM) with a Cavaletti rail in the low position (level of the carpus).By moving the Cavaletti rail to a medium position total hip ROM is improved to 40" to-tal. In a high position (mid antebrachium) total hip ROM is improved to 43" total. It is

Fig. 11. Dancing exercises to encourage hip range of motion and strength. Initially, dancingthe patient forward is less painful and helps to improve gluteal strength. As the patient be-comes stronger, dancing the patient backward is more challenging and leads to improvedhip extension. (From Millis D, Levine D. Canine rehabilitation and physical therapy. 2nd edi-tion. Philadelphia: Saunders; 2016. p. 510; with permission.)

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important to note that Cavaletti rail walking does not improve joint extension.27 Sit-to-stand exercises are beneficial in improving both quadriceps and hamstring musclemass, as well as improving total hip active ROM. Hip extension with sit-to-stand ex-ercises is less compared with walking; however, total hip active ROM is greatlyimproved (66") when compared with walking (36").28 This is beneficial in the early reha-bilitation, when hip extension is still painful, to allow a comfortable exercise that im-proves overall hip active ROM.Aquatic therapy has become very versatile in veterinary rehabilitation. It allows

active muscle contractions with decreased weight bearing on joints and bones. Inpatients with CHD, aquatic therapy can help with muscle spasm, muscle weakness,and pain associated with OA. The most significant benefit of aquatic therapy is likelybuoyancy, which allows the patient to exercise in an upright position and maydecrease pain by minimizing the amount of weight bearing on joints. The higherthe water level, the more stress that is taken off of the joints. With water at the levelof the lateral malleolus of the fibula, dogs support about 91% of their body weight.With water to the lateral condyle of the femur, dogs support 85% of their bodyweight. With water to the greater trochanter, dogs are supporting only 38% of theirbody weight (Fig. 13).29 Another feature of aquatic therapy is hydrostatic pressureand its ability to reduce edema and decrease pain during exercise. This techniqueis thought to decrease a patient’s pain perception, which allows the patient to ex-ercise longer and with less pain.30 An additional feature of aquatic therapy is theresistance needed to move through the water versus air. This resistance can helpto strengthen weak muscles and improve endurance. In patients with OA from asso-ciated CHD, underwater treadmill therapy can improve ROM and comfort, whileincreasing muscular fatigue and building endurance, all while unloading painfuljoints. Initially, many dogs only tolerate 2 to 5 minutes once or twice weekly. Thegoal is to work up to 10 to 20 minutes with as few breaks as necessary. Becauseof the different kinematics of underwater treadmill versus swimming and walkingon dry land, in patients with CHD underwater treadmill therapy is likely more bene-ficial than swimming. Compared with walking on ground, joint flexion is increased inboth underwater treadmill walking and swimming; however, almost near normal jointextension is noted in underwater treadmill therapy compared with swimming, where

Fig. 12. Example of Cavaletti rail walking to help improve active range of motion (flexion).(From Millis D, Levine D. Canine rehabilitation and physical therapy. 2nd edition. Philadel-phia: Saunders; 2016. p. 513; with permission.)


Fig. 13. Amount of body weight borne when immersed in water (A) at the height of thelateral malleolus of the fibula, (B) to the lateral condyle of the femur, (C) at the level ofthe greater trochanter. Therefore, the higher the water level, the more stress that is takenoff of the joints. (From Millis D, Levine D. Canine rehabilitation and physical therapy. 2ndedition. Philadelphia: Saunders; 2016. p. 528, with permission; and Levine D, Marcellin-Little DJ, Millis DL, et al. Effects of partial immersion in water on vertical ground reactionforces and weight distribution in dogs. Am J Vet Res 2010;71:1413–16.)

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hip joint extension is limited.31 Furthermore, walking or trotting in the underwatertreadmill encourages a more normal gait pattern than swimming. For a more in-depth discussion on the indications, contraindications, parameters, settings, andusages for various physical modalities the reader is encouraged to use additionalresources.32–36

In summary, dancing backward maximally increases hip extension, whereas sit-to-stand, ramp descent, ramp ascent, and stair descent minimize hip extension. To-tal hip ROM is maximized with sit-to-stand exercises and dancing forward has theleast impact on total hip ROM. Aquatic therapy can further be added to improvemuscular strength and endurance as well decrease weight bearing on painful bonesand joints. Potential therapeutic exercises used to manage canine CHD are listed inTable 1. For more in-depth therapeutic exercises to improve joint motion,strengthen, improve endurance and speed, the reader is encouraged to read addi-tional sources.37

Physical Modalities to Improve Range of Motion, Comfort, and Function

Physical modalities can be used in rehabilitation therapy to augment therapeutic ex-ercises and promote tissue healing. Modalities such as therapeutic ultrasound, elec-trical stimulation, laser therapy, and extracorporeal shockwave therapy (ESWT) canbe used to manage CHD. Therapeutic ultrasound can be beneficial to patientswith OA associated with CHD by improving ROM and decreasing pain and musclespasm. It allows heating of deeper tissues than cannot be reached with hot packing.Therapeutic ultrasound depth penetration changes based on frequency: 1.0 MHzheats to a depth ranging from 2 to 5 cm and 3.3 MHz heats from 0.5 to 3 cm.38

Hot packing can heat tissue up to 2 cm; however, the greatest temperature changeis noted from the skin surface to approximately 1 cm in depth. The thermal effect oftherapeutic ultrasound may increase collagen extensibility, blood flow, painthreshold, and enzyme activity. Therapeutic ultrasound can be incorporated into arehabilitation protocol in the management of CHD to heat the tissues to furtherimprove stretching and ROM for maximal benefit. To achieve this an intensity of1.0 to 2.0 W/cm2 could be used with either 1.0 or 3.3 MHz frequencies, dependingon dog breed and size. Treatment time varies, but is typically 8 to 10 minutes. Thethermal effects of therapeutic ultrasound are short lived. Therefore, ROM andstretching exercises should occur while the tissue is heated or immediatelyafterward.Electrical stimulation increases muscle strength and ROM, improves muscle tone,

improves pain control, and decreases edema and muscle spasm.39 Neuromuscularelectrical stimulation is used for muscle reeducation, prevention of muscle atrophy,

Table 1Therapeutic exercises potentially included in the management of canine hip dysplasia

Purpose Possible Therapeutic Exercises

Increasing limb strength Daily walk or trot >10 min; tunnel walk, sit to stand,and stand to sit repetitions, swimming

Increasing core strength Daily walk or trot >10 min; swimming

Increasing cardiovascular fitness Daily walk or trot >10 min

Stretching pelvic limbs Climbing up slopes, hills, and stairs; low jumps

Increasing proprioception Daily walk or trot >10 min; walk on soft surfaces: sand,mulch, gravel, leaves, grass; teeter-totter or poleweaving


and enhanced joint movement, whereas transcutaneous electrical nerve stimulation iscommonly used for pain control. In patients with CHD, electrical stimulation can beincorporated into a rehabilitation program to help with long-standing muscle atrophyor selected strengthening of muscle groups (hamstrings, gluteals, or quadriceps) byusing neuromuscular electrical stimulation twice weekly for 10 to 20 minutes. In pa-tients with chronic OA pain associated with CHD, transcutaneous electrical nervestimulation can be used for relief of pain. Treatment can be 2 to 3 times weekly for30 minutes.Laser therapy can be used to relieve pain, reduce inflammation, and increase

microcirculation through the concept of photobiomodulation. The antiinflammatoryand analgesic benefit of laser therapy for patients with OA has been described.40–42

For patients with OA from CHD, 8 to 10 J/cm2 are used and the entire hip area istreated. Start treatment at the greater trochanter, then direct the probe headaround the cranial, medial, and caudal surfaces of the hip in a circumferentialpattern. Because of compensatory changes, referred pain from the lumbosacraland epaxial areas can be treated as well. Treatment protocols vary, but initially 6treatments are applied over 3 weeks, followed by maintenance treatments every3 to 4 weeks. Regardless of the treatment protocol, the treatment is designed toachieve the appropriate dose, number of treatments, and interval betweentreatments.The use of ESWT is centered around the pain-relieving response in patients with OA

from chronic CHD. Shock waves are acoustic waves with various frequencies that aredelivered and travel through soft tissues to the target area. Once the shockwave rea-ches the target, energy is then released, which creates a biologic response promotinganalgesia and decreasing certain inflammatory mediators. The analgesic effect afterESWT is poorly understood, but thought to be due to the release of cytokines andgrowth factors centered around decreasing inflammation and swelling. In dogs withhip OA, ESWT improved ground reaction forces after 4 weeks of treatment, and ben-efits lasted as long as 3 months.43 In a human study of arthritic chondrocytes, inflam-matory factors (tumor necrosis factor-alpha and interleukin-10) were found to bedecreased in patients treated with ESWT when compared with the pretreated chon-drocytes.44 The effects of ESWT on articular cartilage is an area of concern that war-rants additional investigation because preliminary research suggests that high-energyESWT applied directly to cartilage may cause degenerative changes.45,46 Patients aresedated or anesthetized before ESWT. Typically, 500 to 1000 shocks are applied withan energy level of 0.15 mJ/mm2 and 180 pulses/min to the hip region for 2 treatmentsspaced 3 to 4 weeks apart. Improvement may be noted for days to several months af-ter treatment.

Selecting a Treatment Program for a Conservative Approach to Canine Hip Dysplasia

Arthritic dogs with minor locomotion problems will have a treatment programfocused on decreasing pain, maintaining optimal weight, maintaining limb and corestrength, stretching affected joints, and stimulating proprioception. Pain manage-ment is generally achieved with simple pharmacologic steps, rest, and exercise su-pervision and customization. Pharmacologic and other forms of pain relief may beintermittent as long as dogs adhere to a long-term exercise program. Because OAscreening is not done routinely in dogs, OA is most often discovered in its laterstages. Losing mobility because of severe OA is common in large breed dogs. Forpatients with severe OA, it is important to implement all possible support strategiesto decrease the impact of the disease on the dogs’ well-being and mobility. Thesemay include multimodal pharmacologic management, ice, heat, massage,

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acupuncture, acupressure, electroacupuncture, transcutaneous electrical nervestimulation, and rest. Once pain is managed, it is important to initiate an initially con-servative and subsequently progressive exercise program. Patients with severe OAmay need temporary or permanent ambulation assistance. Slings are the most com-mon and cost-effective ambulation assistance devices. Severely impaired dogs maybenefit from an ambulation cart. Underwater treadmills significantly reduce pelviclimb peak vertical force30 and are useful in building muscle in a weight-minimizedenvironment. Overall, a management program for companion animals with OA shouldbe simple and logical. Managing pain is the first priority for all patients. The programmust then address the most critical aspects of each patient’s unique situation and,over time, improve the patient’s mobility, strength, proprioception and, above all,quality of life.

PHYSICAL REHABILITATION AFTER SURGICAL MANAGEMENT OF HIP DYSPLASIA

Surgical intervention is recommended in older patients with debilitating OA that havefailed medical, conservative, and rehabilitative therapies or in younger patients to pro-vide a good, pain-free quality of life. The type of surgical intervention is dictated by theclinical signs present, age, and if the clinical signs of CHD are owing to underlyinglaxity in the early phases or secondary OA in the later phases. Rehabilitation therapyis paramount and in the authors’ opinion considered the standard of care after surgeryfor CHD. Rehabilitation therapy will improve overall comfort, ROM, early usage of thepostoperative limb, and facilitate healing.

Rehabilitation Therapy After Juvenile Pubic Symphysiodesis

The fusion of the medial growth plates of the pubis, referred to as juvenile pubicsymphysiodesis (JPS) is sometimes performed in dogs around the age of 16 weekswith the intent to alter pelvic growth to increase dorsal coverage of the femoralhead. Dogs undergo JPS to control hip subluxation.47 Subluxation persists aftersurgery, but altered growth of the pubis increases the dorsal coverage of thefemoral head by the dorsal acetabular rim. Tissue trauma after a JPS is relativelyminor and does not warrant specific rehabilitation strategies to accelerate theresorption of edema or decrease focal pain. Also, the strength of the pelvis isnot compromised after a JPS, unlike after a double or triple pelvic osteotomy,where the ilium is osteotomized and stabilized with a bone plate. The key aim ofrehabilitation after JPS is to minimize the impact of hip subluxation during skeletaldevelopment. Dogs with hip subluxation will benefit from having strong musclesaround the hip (gluteal muscles, pectineus, adductor, rectus femoris, etc). Growthoptimization is also critical: large breed puppies should not be eating ad libitum (asmuch as they want to eat), they should not overeat carbohydrates, and they shouldnot receive calcium or phosphorus supplementation. The primary focus of rehabil-itation is to promote muscular development of the hind limbs with low-impactexercises.

Rehabilitation Therapy After Triple or Double Pelvic Osteotomy

Triple or double pelvic osteotomies are performed on dogs that have early clinicalsigns of CHD but have not progressed to the point of having significant radiographicevidence of OA. Most dogs that fit these criteria are between 4 and 10 months of age.5

When performed, the triple pelvic osteotomy or double pelvic osteotomy, much like aJPS will improve dorsal femoral head coverage. The technique involves making 2 or 3osteotomies: one in the pubis, one in the ischium (only in triple pelvic osteotomy), and


one in the ilium. The caudal ileal segment is variably rotated, based on the amount ofsubluxation; rotation is commonly 20". A bone plate is applied to stabilize the ilealosteotomy.5

Rehabilitation initially includes specific activity supervision for 4 to 6 weeks toallow bone healing. During this time, nonsteroidal antiinflammatory drugs, cryo-therapy, and passive ROM are used to maintain and normalize hip motion.Controlled, low-impact therapeutic exercises, such as sit-to-stand exercises, andaquatic walking may be useful to attenuate muscle atrophy while avoiding excessivestress on the repair. Muscle strengthening can be achieved using controlledwalking, aquatic walking, and low-impact exercises. The duration of these activitiesis increased gradually during the first 3 months. Dogs are restricted to leash walking,with no running or jumping for the first 3 months to reduce the chances of implantloosening or hip luxation.

Rehabilitation Therapy After Femoral Head and Neck Ostectomy

Rehabilitation after femoral head and neck ostectomy emphasizes gaininghip extension, muscle mass, and active use of the pelvic limb. In the authors’opinion, rehabilitation should imperatively begin within 48 hours after femoralhead and neck ostectomy and continue until normal weight bearing isachieved on the surgical limb. A sample rehabilitation protocol is included inAppendix A.After surgery, nonsteroidal antiinflammatory drugs, cryotherapy, and hip passive

ROM (especially for hip extension) should be performed daily. In addition to passiveROM for hip extension, ambulation on land, a ground treadmill, or an underwatertreadmill can be used to promote active hip extension and weight bearing. Walkingup inclines will emphasize strengthening of the hip extensor muscle groups.Dancing exercises encourage muscle strengthening and improve hip ROM, espe-cially in extension. Most dogs will toe touch consistently within 1 to 2 weeks,bear partial weight in 3 weeks, and be actively using the leg by 4 weeks. Deep heat-ing (up to 5 cm) may be accomplished by the use of therapeutic ultrasound,48 andmay be performed before stretching. The animal should regain near-normal walkingand trotting gaits, but full ROM is rarely achieved, with hip extension being the mostlimited. Prognosis for return to daily function is good, but varies with the chronicityof the preexisting lameness and the presence of comorbidities. The dog’s overallathletic ability will likely be decreased. Large dogs tend to have more difficultywith recovery than small dogs, and unfit and obese dogs tend to have more difficultythan fit and athletic dogs.

Rehabilitation Therapy After Total Hip Arthroplasty/Replacement

Total hip replacement (THR) is a well-established management option for dogs withsevere CHD. THR is generally delayed until CHD can no longer be managed by theuse of medical therapy and exercise.Rehabilitation after THR can be divided into conventional rehabilitation, performed

in uncomplicated patients, and targeted rehabilitation, performed to address specificsituations relating to THR.

General rehabilitation after total hip replacementThe goal of rehabilitation after THR is to restore the long-term, pain-free use of theoperated limb.49 Several retrospective and a few prospective studies of canineTHR have been published.50–52 These studies included little information regardingpostoperative rehabilitation beyond initial supportive care and progressive leash

Dycus et al838

walks. In a long-term prospective clinical trial in which physical rehabilitation waslimited to walking dogs on a leash to void during the first 2 months after surgeryand increasing the length of leash walks during weeks 9 to 12, hip passive ROMwas normal in 29 of 31 dogs (94%) that were free of complications 5 years aftersurgery.52 Hip extension was decreased in 3 dogs with long-term implant luxationand in 1 dog with a femoral osteosarcoma. In the same study, thigh girth was equalto or greater than the opposite thigh in all dogs that were complication free. To ourknowledge, there are no published reports describing dogs that did not achieveproper limb function after THR, provided that the hips were free of implant malpo-sition, infection, fracture, or failure of fracture fixation. Functionally, dogs undergo-ing routine THR have normal limb use 3 months after surgery.51 This suggests thatspecific rehabilitation programs or long hospitalization periods are probably notnecessary for the success of uncomplicated THRs, but they may be consideredin patients with limited hip motion because of tissue tightness. For example,some patients with dorsal femoral displacement for extended periods before sur-gery have tight periarticular muscles and other soft tissues after joint replacement.Rehabilitation includes acute, subacute, and chronic phases. Acutely, the rehabili-

tation after THR is focused on providing pain relief, and avoiding catastrophic compli-cations, including implant luxation or femoral, fracture. Subacute rehabilitation afterTHR is focused on completing the recovery of joint motion and strengthening of theoperated and contralateral limbs. Because healing is still progressing, exercises thatwould place excessive stress on the joint capsule and bone–implant interfaces areavoided. Excessive stress on the joint capsule could result from external rotation,from excessive adduction, or from excessive abduction of the operated limb. Walkingexercises are generally performed in a straight line. Slippery and unsteady surfacesare avoided.Chronic rehabilitation after THR is focused on strengthening the operated and

contralateral limbs. A wider range of therapeutic exercises is introduced and the inten-sity of these exercises increases over time (Fig. 14).

Targeted rehabilitation after total hip replacementTissue tension Dogs with limited hip extension will benefit from a stretching pro-gram. When the loss of hip extension is severe, moist heat and manual stretchingtechniques are used. Extension uses a spinning motion of the femoral head onthe acetabulum and thus tightens the joint capsule at end ranges. This is a safedirection for stretching with regard to limiting the possibility for luxating the hipwith overzealous motion, but care must be exercised to not cause thepatient pain with this stretch. After the stretching session, active hip extension ex-ercises should be performed to retrain the patient to use increased ROM. Manualstretching is not critical when the loss of hip extension is modest and the patient’slimb use is acceptable. Some patients are not receptive to stretching techniquesand owners may not be able to safely perform stretching at home. In thesesituations, targeted therapeutic exercises alone can be used instead to gain hipextension for a more normal gait pattern and better function. Walking up agentle incline, stepping up a single step or a series of steps with adequate trac-tion, and stepping over objects all place the trailing limb in increased hipextension.

Sciatic neurapraxia Patients with sciatic neurapraxia typically present with knucklingand weakness of the muscles in the sciatic distribution, including the hamstringsand crus musculature. Dogs exhibiting deficits owing to sciatic neurapraxia after


THR need rehabilitation for days to months, depending on the severity of the defi-cits.53 Rehabilitation focuses on minimizing hip complications owing to decreasedactive muscular stabilization and protection (such as luxation), avoiding skin abra-sions resulting from scuffing or knuckling, decreasing the loss of muscle mass inmuscles innervated by branches of the sciatic nerve, and strengthening the affectedmuscle groups. Neuromuscular electrical stimulation can be used to elicit musclecontractions of the affected muscles to attenuate atrophy,33 but is not universallywell-accepted by patients. If active hock extension is absent for weight bearing,the hock can be stabilized by an orthosis during therapeutic exercises (Fig. 15).Once hock extension improves, the dog can exercise without an orthosis.54 Toavoid abrasions, affected dogs should avoid walking on abrasive surfaces andmetacarpals and toes should be protected by a thin bootie or bandage. If the patientfrequently knuckles, bootie systems with support straps that pull the hock intoflexion and the digits into extension (TheraPaw, Lebanon, NJ) can be used duringambulation and therapeutic exercise sessions to create a more normal posture forfunctional limb use while simultaneously protecting the skin from abrasions. Indogs with weak hock flexion, an exercise band or rubber traction band (Anti-

Fig. 14. Example of a patient walking on a land treadmill after a total hip replacement forsevere canine hip dysplasia. This patient had previously had a contralateral mid-femoralamputation. Note the sling being used to support the pelvic limb so the patient cannotslip or fall during the exercise session. (From Marcellin-Little DJ, Doyle ND, Pyke JF. Physicalrehabilitation after total joint arthroplasty in companion animals. Vet Clin North Am SmallAnim Pract 2015;45(1):151; with permission.)

Dycus et al840

Knuckling Device; Canine Mobility, Seattle, WA; or Biko Mobility, Raleigh, NC) canbe used to facilitate more normal flexion ROM during exercises. Exercises tostrengthen hock flexion include stepping over progressively taller objects, such assegments of PVC pipe, walking in water at the height of the hock, and elicitationof a flexor withdraw reflex by pinching the digits. Most dogs fully recover fromsciatic neurapraxia.53

Implant luxation (dorsal/ventral) After the acute management of a luxation, eithertraumatic or after a THR (with reduction/hobbles and/or surgical revision), targetedstrengthening of the appropriate muscle groups provides improved dynamic jointsupport to help prevent a recurrence. Dogs that experienced a dorsal luxationneed additional strengthening of the muscles lying on the dorsal aspect of the hip.Suggested exercises include 3-legged standing (lifting the unaffected pelvic limband cuing the dog to shift weight onto the operative limb while maintaining a levelpelvis), balancing on a soft or unsteady surface (commercial balance discs or anair mattress), walking perpendicular to an incline with the operative limb “downhill,”and the previously mentioned hip extension exercises. Dogs experiencing a ventralluxation require strengthening of the adductors. Suggested exercises includeresisted TheraBand exercises (TheraBand, Akron, OH) while walking on a treadmill

Fig. 15. A patient with sciatic neurapraxia after a total hip replacement. In the upper image,the patient is wearing a tarsal orthotic, which will allow the patient to exercise withoutscuffing or knuckling while walking. Use of underwater treadmill therapy allows the patientto exercise without scuffing or knuckling. (From Marcellin-Little DJ, Doyle ND, Pyke JF. Phys-ical rehabilitation after total joint arthroplasty in companion animals. Vet Clin North AmSmall Anim Pract 2015;45(1):159; with permission.)


or alongside the handler (pull the hip into abduction with the band wrapped aroundthe thigh to stimulate a contraction of the adductors), walking sideways, or walkingperpendicular to an incline with the operative limb “uphill.” Underwater treadmillwalking also can effectively and safely target the desired muscle group in both situ-ations,58 particularly in the earlier phases of recovery. Proprioceptive retrainingshould also be used to improve body awareness and coordination for decreasedrisk of future falls.

SUMMARY

The goals of rehabilitation therapy at various stages of CHD vary. Initially, clinicalsigns and discomfort are thought to be owing to the underlying laxity. This laxity re-sults in lateralization of the femoral head during the swing phase of the gait with a“catastrophic reduction” of the femoral head into the acetabulum during foot strike.Rehabilitation therapy as part of conservative management in patients with laxity orin older patients with OA is centered around maintaining pain control and comfortwhile improving hip ROM in extension and maintenance of muscle mass. This isaccomplished with weight reduction and fitness, minimizing joint pain, pharmaceu-ticals, disease-modifying osteoarthritic agents, manual therapies, therapeutic exer-cises, and physical modalities. Surgical therapy for patients with CHD is focused atimproving femoral head coverage and reducing the development of OA (JPS, triplepelvic osteotomy/double pelvic osteotomy) or removing the source of discomfort(femoral head and neck ostectomy or THR). Initially, rehabilitation therapy isdesigned to improve overall postoperative comfort, ROM, early use of the postop-erative limb, and facilitate healing. The later stages of rehabilitation therapy arecontinuation of improvement in ROM and muscle mass to facilitate return to functiononce surgical healing is satisfactory. Each aspect of rehabilitation such as manual,therapeutic, and physical modalities follows a multimodal patient centeredapproach.

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PhaseExpectedTimeframea Rehabilitation Clinic Program Home Program

Outcome AssessmentMeasures

Criteria for Movement to NextPhase

Non–weightbearing totoe-touching

Immediate to48–72 hpostoperative

Therapeutic exercisesSlow, gentle hip pROM for

operated limb focusing onextension (10 reps TID-QIDbeginning immediatelypostoperative whilerecovering fromanesthesia)

Slow leash walking withsling support available,only to go outside (up to5 min, TID-QID)

Balance exercises on a softfoam pad or bidirectionalbalance board for weightbearing

ModalitiesGentle massage around the

surgery site, thigh andlumbosacral regions

Transcutaneous electricalstimulation for pain relief(15–20 min SID-TID)

Cryotherapy (15–20 min TIDafter activities) – firstsession immediatelypostoperative incombination with slowpROM while recoveringfrom anesthesia

Therapeutic laser therapySID

Inpatient status preferredduring this phase

If home:Therapeutic exercises

Slow, gentle hip pROMfor operated limbfocusing onextension (10 repsTID-QID beginningimmediatelypostoperative)

Slow leash walkingwith sling supportavailable, only to gooutside (up to 5 min,TID-QID)

Balance exercises on asemifirm surface forweight bearing

ModalitiesGentle massagearound the surgerysite, thigh andlumbosacral regions

Cryotherapy(15–20 min TID afteractivities) – firstsession immediatelypostoperative

Postoperative bilateral“hip” pROM and otherjoints as applicable viagoniometry

Postoperative bilateralthigh circumference

Response to activity andsubjective pain level

Lameness score at a stanceand walk

Weight

Early toe-touchingAdequate resting analgesiaDecreased perioperative

swelling and lack ofincisional drainage.

APPENDIX A: SAMPLE PROTOCOL FOR FEMORAL HEAD AND NECK OSTECTOMY

Dycu

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846

Early weightbearing

72 h to 2 weekspostoperative

Therapeutic exercisespROM and flexion/extension

hip stretches of operatedlimb (10–15 reps BID-TID).Bicycling and flexor reflexexercises

Slow, controlled walking ona land treadmill, 5–10 minincluding mild inclinesettings to encourage hipextension and targetgluteal muscles

Balance exercises on a softfoam pad or bidirectionalbalance board for weightbearing BID-TID

ModalitiesHeat therapy before activity

(10–15 min BID-TID, notwithin 72 h after surgeryor if S/S of acuteinflammation are stillpresent)

Therapeutic ultrasound SIDMassageTherapeutic laser therapy

PRNCryotherapy (15–20 min BID)

after exercises

Therapeutic exercisespROM and flexion/

extension hip stretchesof operated limb(10–15 reps BID-TID)

Slow, controlled leashwalking, 5–20 minincluding mild inclinesto encourage hipextension and targetgluteal muscles

Balance exercises on asoft foam pad forweight bearingBID-TID

ModalitiesHeat therapy (10–15 min

BID-TID, beforeexercises, Not within72 h after surgery or ifclinical signs of acuteinflammation are stillpresent)

Cryotherapy (15–20 minBID) after exercises

Goniometry - hip ROM andother joints if applicable


Lameness score at a stanceand walk

Weight

Consistent partial weightbearing on operated limb onall strides at a walk

Minimal pain with lightactivities

Incisional healing withoutcomplications

(continued on next page)

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(continued )




Consistentweightbearing atwalk

2–4 wkpostoperative


hip stretches of operatedlimb (10–15 reps SID-BID

Controlled walking on a landtreadmill, 10–15 min withincreased incline angleand speed SID

Balance exercises on aninflatable disk or 360"

wobble board for weightbearing 5 min BID-TID

Encourage increased weightbearing on operated limb(examples: initiatingdancing exercises astolerated 5 min BID-TID,applying weight onoperated limb at 3%–5%bodyweight or syringe capunder contralateral foot)

Sit-to-stand exercises 5–10reps BID

Aquatic therapy: UWTMwalking 5–10 min onceincision is sealed SID-BID

Swimming 3–5 d per weekCavaletti Rails 5–10 reps BID

ModalitiesHeat therapy before activityTherapeutic ultrasound PRNMassage PRNTherapeutic laser therapyPRNCryotherapy (15–20 min BID)

after exercises


extension hip stretchesof operated limb(10–15 reps BID-TID)

Leash walks 15–20 minincluding 5–10 min ofinclines

Balance exercises on aninflatable disk forweight bearingBID-TID

Sit-to-stand exercises5–10 reps BID

Light jogging 3–5min perday

Stairs: 1 flight SID-BIDModalities

Heat therapy (10 min)before activity

Cryotherapy (15–20 min)after exercises


Reevaluate thigh musclegirth at 3–4 wkpostoperative


Lameness score at a stance,walk and trot

Weight

Consistent weight bearing onoperated limb on all stridesat a walk, consistent partialweight bearing at a trot

Minimal pain with lightactivities

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848

Consistentweightbearing ata trot

5–8 wkpostoperative


hip stretches of operatedlimb PRN

Controlled walking or lightjogging on a landtreadmill, 15–20 min withincreased incline angleand speed SID

Balance exercises on aninflatable disk or 360"

wobble board for weightbearing 10 min BID-TID

Sit-to-stand exercises 10–20reps BID

Aquatic therapy: UWTMwalking 15–30 min SID-BID

Swimming 2–5 d per weekModalities

Heat therapy PRN beforeactivity

Cryotherapy PRN afterexercises


extension hip stretchesof operated limb PRN

Leash walks 20–30 minincluding up to10–15 min of inclines,may use weights onaffected limb or pulledwith a harness astolerated/required

Incorporate challengingsurfaces to walks thatis, snow, sand, whenpossible

Controlled ball-playingwith graduallyincreasing times anddistances

Sit-to-stand exercises10–20 reps BID

Light jogging 3–5 min/dStairs: 2–4 flights SID-BID

ModalitiesHeat therapy PRN before

activityCryotherapy PRN after

exercises


Reevaluate thigh musclegirth at 7–8 wkpostoperative



Weight

Consistent weight bearing onoperated limb at a trot

Minimal to no pain withmoderate to extensiveactivities

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(continued )




Trotting atspeed withminimal tonolameness

Nine wkpostoperativeand beyond

Aquatic therapy as desired;otherwise exercises may becontinued as part of a homeexercise program

Therapeutic exercisespROM for operated limb

PRNLeash walks at times and

distances tolerated,including fast walks upinclined surfaces

Sit-to-stand exercises20–30 reps as needed

Jogging: working upfrom 10-15 min per day

Stairs: walking andtrotting, increasingnumber of flights astolerated

Swimming or walking inmid-to-upper-thigh-level water

Ball playing withgradually increasingtimes and distances,becoming morevigorous over time

Goniometry every 3–4 wk ifneeded

Reevaluate thigh musclegirth every 3–4 wk PRN



Weight

Consistent weight bearing onoperated limb at a trot;permanent mild gait deficitsmay persist

Minimal to no pain withextensive activities

Abbreviations: PRN, as needed; pROM, passive range of motion; QID, 4 times a day; reps, repetitions; S/S, signs/symptoms; SID, 1 time a day; TID, 3 times a day;UWTM, underwater treadmill.

a This protocol is for use by licensed veterinary professionals. It is intended as a guideline, and may be influenced by many factors affecting individualized pa-tient care.

Dycu

setal

850

physical rehabilitation for the management of canine hip

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